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The researchers found that of 22,956 patients given second-line treatment, only 8.2% had evidence of recommended use of metformin in the prior 60 days, and 28.0% had no prior claims evidence of having taken metformin. Only 49.5% of patients could have had recommended use. An additional second-line antihyperglycemic medication or insulin was more likely in patients given their initial second-line medication without evidence of recommended use of metformin (P<0.001).

“Despite published guidelines, second-line therapy often is initiated without evidence of recommended use of first-line therapy. Apparent treatment failures, which may in fact be attributable to nonadherence to guidelines, are common,” the authors write. “Point-of-care and population-level processes are needed to monitor and improve guideline adherence.”